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General NPI Number Information
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NPI Number | 1700166956
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Entity Type | Organization
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Legal Business Name | STRUCTURAL BASED THERAPY, LLC
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Dates
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Enumeration Date | 08/19/2011
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Last Update Date | 08/19/2011
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Provider Practice Location Address
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Address Line | 3719 OLD ALABAMA RD SUITE 400 A
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City | ALPHARETTA
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State | GA
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Zip | 30022-8675
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Country | US
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Telephone | 678-469-4133
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Fax |
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Provider Business Mailing Address
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Address Line | 3719 OLD ALABAMA RD SUITE 400 A
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City | ALPHARETTA
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State | GA
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Zip | 30022-8675
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Country | US
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Telephone | 678-469-4133
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL ANGELO MAIORINO
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Credential | DC
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Telephone | 678-469-4133
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | X009403-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MT004280
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIR008110
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License Number State | GA
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